Blog Posts (87)

April 1, 2016

In March, the Indiana legislature passed and the Indiana
governor signed into lawHB
1337, a bill that bans abortions for women seeking them based solely on
certain characteristics of the fetus, such as race, sex, and disability.
Specifically, the bill:

“Prohibits a person from performing
an abortion if the person knows that the pregnant woman is seeking the abortion
solely because of: (1) the race, color, national origin, ancestry, or sex of
the fetus; or (2) a diagnosis or potential diagnosis of the fetus having Down
syndrome or any other disability. Provides for disciplinary sanctions and civil
liability for wrongful death if a person knowingly or intentionally performs a
sex selective abortion or an abortion conducted because of a diagnosis or
potential diagnosis of Down syndrome or any other disability.”

As I have discussed in a previous
blog, sex selection is a frequent occurrence in certain countries, such as
India and China, where there is a strong preference for sons. Yet, there is
little to no evidence that sex selection abortion is commonplace in the US. Abortion
based on the race of the fetus is similarly rare in the US. While the purpose
of any law is to prohibit actions it deems unethical or contrary to social
norms, regardless of their frequency, due to limited time and resources, it
makes sense to focus on bills that address common occurrences or things that
are so morally repugnant that the state must take a stand. The main motivating
factor for this bill does not seem to be avoiding discrimination based on sex
and race, but rather trying to undermine legal access to abortion. Indiana is
one of only five states that does not have a hate crime law and it recently rejected
another attempt to pass hate crime legislation. It seems odd, and even
contradictory, that Indiana is so worried about discrimination against fetuses,
but not against legal persons.

The provision outlawing abortion due to disability is also
troubling. Women and their families are often faced with very difficult
decisions if they find out a fetus they are carrying has a disability and they should
have the autonomous right to make decisions that are best for themselves and
their families. This bill does allow women carrying fetuses with lethal
abnormalities to abort, but they first have to receive materials about
perinatal hospice care and complete documentation stating that they received
such materials. The knowledge that the fetus has a lethal abnormality is
devastating to many women and the idea of carrying the pregnancy to term is often
psychologically distressing for them. Requiring them to be counseled about
perinatal hospice care seems unnecessary and insensitive. Good physicians
already ensure that their patients are adequately informed about their options and
this seems to be a form of directive, morally laden counseling that will just
make women feel guilty, rather than expanding their choices.

Another aspect of this bill that is quite problematic is
that it “Provides that a miscarried or aborted fetus must be interred or
cremated by a facility having possession of the remains.” For most abortions,
the fetal remains are disposed of with other medical waste. This law, however,
requires that the fetal remains are buried or cremated. This is clearly an
attempt to elevate the status of the fetus and give it equal rights to legal
persons.

This law means that Indiana now has some of the most
restrictive abortion laws in the country. While many antiabortion supporters
are in favor of this law, it is worth noting that some antiabortion
legislators think this bill goes too far. They are concerned that this bill
lacks compassion and demeans women. I agree with these concerns and am troubled
by the passage of this law for the reasons I have outlined here.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

March 24, 2016

Who could be against life? Ancient natural law theory in the
Catholic tradition tells us that human beings desire to live, and that life is
good, therefore humans have an obligation to live and not kill other human
beings. This ancient wisdom has been instilled into western ways of moral
thinking. So, who could not be prolife in terms of how we place value on all
individual human life?

Who could be against human freedom? Individual human beings
should be free to live peacefully in accordance with their own values and life
goals. This is a basic tenet of democracy that has shaped moral and political
thinking in the West for the past four centuries. So, who could not be against
the exercise of free choice, especially about something so basic as having
control over our bodies?

The two value perspectives contained in the prior two
paragraphs, all things equal, are eminently reasonable and most ethically unproblematic.
These two value positions represent two fundamental principles of ethics—the
intrinsic value of all individual human lives and the right of free individuals
to govern their own lives and bodies—that guide us in living an ethical life
and making ethical decisions. It is when these fundamental principles come into
direct conflict that a serious, a near irresolvable, ethical conflict arises.
There is no greater direct conflict of these two ethical principles than right
of women to have an abortion. It is commonly assumed that one is either on one
side of this moral abyss or the other and the twain shall never meet. It seems
to me one of the central tasks of ethical reflection on this issue is to find
as much meaningful middle ground as possible. In this brief blog I’ll offer a
few ideas in this regard, which advocates on either extreme will likely find unsatisfactory.

Once a fetus reaches full term and emerges at birth into the
world as a separate human being, there is no question about its full moral
standing—from my perspective this would include babies with the most serious
birth defects, including anencephaly. Some bioethicists believe that a being
must have interests to have full moral standing. Since babies with anencephaly,
if they survive a short time after birth, have no brain, no capacity to
experience pain or pleasure, and no future life, they have no interests. The
latter may be true descriptions of babies with this disorder, but they are
unequivocally individual human beings. And there is no reason, as the law
currently supports, to justify killing or euthanizing the lives of these babies
in my view. So can’t the same be said of a fetus from the moment of conception?

It is true that a human embryo is a biologically a distinct
form of individual human life and because of that fact has moral worth and
deserves respect. But there is a basic aspect of fetal life even after
viability and prior to birth that is inescapable: the fetus is dependent on the
mother for its life and is part of the woman’s body. There is no protecting the
fetus prior to birth without controlling the bodies of pregnant women. At the
same time, at the very least, abortion as I am defining my terms is morally
concerning and even problematic. I realize many of my pro-choice friends will
find that conclusion concerning, but it is simply a consequence of recognizing
the moral humanity of fetal life. So the key question then becomes who should
make this moral or ethical decision and how should abortion services be regulated
under the law?

A moderate position that seeks to preserve as many values as
possible in this conflict, it seems to me, will recognize elective abortion as
a moral issue but will reject the notion that it should be restricted as a
service under the law. For if the law seeks to protect fetal life by
restricting abortions, ipso facto, it also seeks to restrict the liberty of the
woman to control her body as she so desires. The idea of requiring a woman to
keep an unwanted pregnancy is an assault to her dignity as free human being. We
cannot pretend to live in a free society where men and women have equal moral
worth if we do not extend full moral autonomy to both men and women equally.

I conclude abortion is a moral issue and like many moral
issues they are decisions that individual free human people should make and
should not be the business of government to regulate. But it is not trivial to
recognize abortion as a moral issue. We should not only talk, but also act,
like all human life as value. We can provide adequate healthcare to all people,
which should include family planning, prenatal, and birth control services for
woman. We should provide more day care for parents, particularly single parents
and other support services to make having children easier.

In short we can be a society that acts like it values all
human life, of which fetal life is a part. But the ethical position of valuing
all human life in terms of ascribing full moral standing to individual human
beings cannot extend individual fetal life if we are to full value women as
autonomous human beings.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, aDoctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

March 15, 2016

Whereas quality of life issues for cancer patients used to
minimized, and sometimes even ignored, today there is more of a focus on cancer
patients’ quality of life post-cancer. One such quality of life issue is oncofertility,
which is fertility preservation for cancer patients. In many places,
oncofertility is, or is becoming, the standard of care for cancer patients. But
should it be offered to all patients? What about patients who have a very bad
prognosis?

Fertility preservation for patients with a poor prognosis
raises a host of ethical issues. Providers may worry that discussing fertility
preservation will give patients false hope about their prognosis. In other
words, these patients may feel their providers deceived them by mentioning
fertility preservation, leading them to believe that their prognosis is not as
bad as they originally thought.

Yet, at the same time, pursuing fertility preservation may
be a source of hope and happiness for patients during difficult times. It may
furnish them with mental and physical strength, making them even more motivated
to survive for the sake of their potential future children. Additionally, these
patients, and their families, may feel a degree of inner peace knowing that
part of their lives will continue on in the reproductive material even if they
are never used.

Nevertheless, some may argue that, despite any personal and
emotional benefits they may experience, offering patients with a poor prognosis
fertility preservation options is an unjust allocation of resources. From a
utilitarian perspective, it does not make sense to devote resources to patients
who will likely not benefit from them. Put differently, resources should be
allocated to those who have a high probability of a positive outcome, which
means individuals with a poor prognosis should be placed lower on the priority
list for receiving fertility preservation resources than individuals with a
good prognosis.

On the other hand, if we take a deontological (duty-based,
individual rights) approach, providers have a duty to care for their patients.
Not offering fertility preservation to all of their patients, including those
with a poor prognosis, may be seen as diminishing patient autonomy. According
to this view, providers should be more concerned with the needs and rights of
their individual patients than with social justice (i.e., fair allocation of
resources).

For more on this topic, see my book chapter “Addressing the
Three Most Frequently Asked Questions of a Bioethicist in an Oncofertility
Setting” in Oncofertility Medical
Practice, edited by T.K. Woodruff and C. Gracia.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, aDoctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

March 8, 2016

The Zika virus is spreading rapidly throughout parts of South and Central America. Public health officials are concerned because there is a correlation between the emergence of the Zika virus and a dramatic increase in number of babies born in Brazil with a severe birth defect called microcephaly.…

February 10, 2016

The New York Times recently reported that physicians will soon undertake the first penis transplants in the U.S. The goal of this procedure is to restore everyday functionality as well as sexual functioning for men with genitourinary injuries, which are injuries involving loss of part of all of the penis and/or testicles. The donated penis will come from a deceased donor, with that donor’s permission. Penis transplants have only taken place in China in 2006, where the procedure failed due to the recipient psychologically rejecting the transplant, and in South Africa in 2014, where the procedure was successful.

For the time being, this procedure will be limited in the U.S. to men who lost their penis in military service. In the last 15 years, over 1300 men have suffered genitourinary injuries in Afghanistan or Iraq, mainly due to homemade bombs. Almost all of these men are under 35 years old.

One objection to penis transplantation is that it is not life-saving. While it is true that penis transplants are not life-saving, much of modern medicine focuses on improving quality of life (e.g. glasses for poor vision, over the counter medication for the common cold, physical therapy for back pain, assisted reproductive technologies for infertility, etc.). While a genitourinary injury may not be visible to others, the effect on the individual can be devastating. For many men, the penis is a symbol of his masculinity and not having “normal” genitals can impair his gendered and sexual identity. As I have discussed in my published research,

“the male genitals are generally central to a man’s coherent sexual identity, and are associated with stereotypical masculine traits like “strength” and “courage.” Because of the personal, as well as social, significance of the male genitals, having “misfunctioning” (e.g. impotent, prematurely ejaculating, infertile) genitals or genitals that look “abnormal” (e.g. small penis, missing a testicle) can diminish men’s sense of masculinity.”

Given the significance of the male genitals to men, it is not surprising that many male patients find a genitourinary injury to be the worst type of injury possible. According to Scott E. Skiles, the polytrauma social work supervisor at the Veterans Affairs Palo Alto Health Care System who is quoted in the New York Times article on penis transplants, “Our young male patients would rather lose both legs and an arm than have a urogenital injury.”

The psychological suffering caused by genitourinary injuries should not be underestimated. The objection that a penis transplant is merely “elective” and not medically necessary overlooks the profound effect a genitourinary injury can have on a man’s mental health. While there are still concerns about penis transplants, namely the fact that they are still experimental, they should not be equated with other types of surgeries that purely or mostly cosmetic.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, aDoctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

February 3, 2016

In this month’s issue of AJOB, Howard Minkoff and Mary Faith Marshall argue that we ought to acknowledge the inherent complexity and personal nature of risks involved in childbirth, and thus defer, when possible, to the decisions made by autonomous mothers-to-be.…

January 28, 2016

Gestational surrogacy contracts have been in the
news again recently as a gestational surrogate reports
that the intended father, having discovered that she is expecting triplets, is
demanding that she undergo selective reduction to abort one of the fetuses. Situations such as these, while often not reported,
are not necessarily uncommon. In 2013, a
gestational carrier was offered $10,000 to abort
when a second trimester ultrasound discovered congenital heart and brain
abnormalities. Despite a
well-established Constitutional right to privacy that includes a pregnant
woman’s right to procure – or refuse – an abortion, surrogacy contracts
routinely include provisions that not only prohibit a surrogate from having an
abortion unless there is a medical need, but also give the intended parents sole
discretion to determine whether the surrogate should abort where there is
evidence of a physical abnormality or other issue. Such provisions have not been tested in court,
but would almost certainly be unenforceable based on the surrogate’s Constitutionally-protected
right to reproductive autonomy.

In India, where there is an estimated $400 million
surrogate tourism industry, women agree to be surrogates in exchange for
$5,000-7,000, which is far more than they could make otherwise. In many clinics, surrogates live in
dormitories for the duration of the pregnancy and their food and medical care
is provided by the clinic. There are
also reports that some clinics have policies against pregnancies of 3 or more fetuses
– meaning that selective reduction may occur as
a matter of course to reduce the number of fetuses
to 2 or 1. If this is in fact happening,
are the surrogates (or even the intended parents) aware of what is
happening? Are they given a voice in the
medical care and treatments they receive?
Or are the decisions made by the intended parents or the clinic, and
simply imposed on the surrogate?

Surrogacy, as with other assisted reproductive
techniques, has been promoted in the name of reproductive autonomy – the right
and ability to have more options and exert more control over reproduction.But in cases such as these, where surrogates are
pressured legally, financially and socially to have an abortion, whose
reproductive autonomy are we honoring?While it may be the child of the intended parents, it is the uterus of
the surrogate.The intended parents have
an interest in the healthy development and birth of their child, which can be
affected by congenital abnormalities, surrogate behavior, or the presence of
multiples.The surrogate has an interest
in her own bodily integrity, her own health, and the treatments or procedures
performed on her, even in connection with the gestation of another’s child.Where these interests conflict, whose rights
are stronger: the intended parents of the child, or the woman carrying it?

It seems unconscionable that a woman could be forced
to undergo an abortion based on enforcement of a contract.It is equally disturbing to think that an
intended parent would be prevented from objecting to an abortion of his or her
child because the surrogate was making the decision to abort.While both of these decisions in the context
of a commercial surrogacy arrangement may be considered a breach of contract,
and therefore may have monetary damages, what is left in the aftermath?A parent whose unborn child was aborted
without the parent’s permission?A
surrogate who has been abandoned with a newborn she never intended to keep?These consequences are far weightier than
could be compensated for by money.

The problem with blending the rights of reproductive
autonomy is trying to separate them again when there is a conflict. A surrogate will always have the right to determine
what happens to her body, which includes the right to have or refuse an
abortion, even if the child belongs to someone else. Is it possible, then, to simultaneously protect
the reproductive rights of both the surrogate and the intended parents? Or will there always be an inherent imbalance
of reproductive rights and the potential for coercion in the enforcement of
commercial surrogacy agreements?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, aDoctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 5, 2015

<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">A Catholic hospital </span><a style="font-size: 11.2px; line-height: 19.04px;" href="https://www.rt.com/usa/315359-catholic-hospital-denies-sterilization-request/">came under fire recently</a><span style="font-size: 11.2px; line-height: 19.04px;"> for stating that it would not permit doctors to perform a tubal ligation during a c-section scheduled for October. According to news reports (including an</span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://www.thedailybeast.com/articles/2015/09/23/a-catholic-hospital-says-it-s-evil-for-me-to-get-my-tubes-tied.html">article written by the patient herself</a><span style="font-size: 11.2px; line-height: 19.04px;">), the pregnant patient has a brain tumor, and her doctor have advised her that another pregnancy could be life-threatening. Her doctor has recommended that she have a tubal ligation at the time of her c-section. While my knowledge about this hospital, this case, and the participants is limited to what has been reported in the media, it raises an interesting question: in our pluralistic society, where conscientious objection is respected while maintaining a patient’s right to a certain standard of care, is it ethical to allow a religiously-affiliated health care institution to refuse to provide certain treatments it finds morally objectionable?</span></p>
<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">As background, the Catholic Church has historically been outspoken on bioethical issues and has a strong and robust bioethical teaching. Catholic hospitals are governed by the </span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf">Ethical and Religious Directives for Catholic Health Care Services</a><span style="font-size: 11.2px; line-height: 19.04px;"> (ERDs), a document promulgated by the United States Conference of Catholic Bishops (USCCB) that clearly articulates the bioethical policies that must be followed in a health care institution based on the Church’s moral teachings. It explains the Church’s teaching against direct sterilization as a method of birth control based on the </span><a style="font-size: 11.2px; line-height: 19.04px;" href="http://plato.stanford.edu/entries/double-effect/">principle of double effect</a><span style="font-size: 11.2px; line-height: 19.04px;">. “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.” (Directive 53). In other words, if the sterilization procedure directly treats a pathology, it is licit; if it is used as a form of birth control to prevent a pregnancy, even if that pregnancy would be life-threatening, it is not licit.</span></p>
<p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>

October 1, 2015

<p style="font-size: 11.2px; line-height: 19.04px;">Savior siblings are children who are born to provide HLA compatible body parts, typically umbilical cord blood to be used for bone marrow transplantation, in order to save the life of their older sibling. They are created using IVF so that the embryos can be screened in order to find and implant one that is a match to the existing child. The <a href="https://en.wikipedia.org/wiki/Adam_Nash_(savior_sibling)">first savior sibling</a>, Adam Nash, was born in the US was born in 2000. Lisa and Jack Nash decided to create a savior sibling after their doctor suggested it might be the best option for a cure for their daughter Molly, who was born with a severe type of Fanconi anemia. Immediately after Adam was born, Molly received a bone marrow transplant using the umbilical cord blood from her brother. The notion of savior siblings gained more attention with Jodi Picoult’s book <em><a href="http://www.jodipicoult.com/my-sisters-keeper.html">My Sister’s Keeper</a></em> and the <a href="http://www.imdb.com/title/tt1078588/?ref_=nv_sr_1">movie based on the book</a>. In contrast to Adam Nash, the savior sibling in the book and movie is expected to continue giving bodily to her sister throughout her childhood, including organ transplantation, rather than one time umbilical cord donation.</p>
<p style="font-size: 11.2px; line-height: 19.04px;">Is it ethical for parents to create a savior sibling? Some argue that the parents’ intention plays a role in considering whether it is ethical to create a savior sibling. If the parents were not planning on having any more children and they are the having the savior sibling only for the sake of the older child, then there is the concern of using the savior sibling as a means to an end. If the parents were planning on having more children, then some claim that the savior sibling is wanted for her/his own sake and is not being created for just one purpose (i.e. to save the older child).</p>
<p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate
of Professional Studies in Bioethics, and Graduate Certificates in
Clinical Ethics and Clinical Ethics Consultation. For more information
on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>